Sample Proposal I - The Commonwealth Fund

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Examples include the Agency for Healthcare Research and Quality, the Hospital ... (such as reports by health care organi
EXEMPLAR PROPOSED HARKNESS PROJECT I

THE COMMONWEALTH FUND 20XX–20XX HARKNESS FELLOWSHIPS IN HEALTH CARE POLICY AND PRACTICE APPLICATION FORM PRELIMINARY RESEARCH PROPOSAL

“Policy and Organizational Strategies to Reduce Clinical Performance Variations” A. Purpose and Context: Performance variations among clinical staff in health care settings naturally mean that patients receive differing quality of care.1 2 Such differences have been a core concern in the effort to improve quality, as represented in a substantial body of primary data that has been collected and analyzed.3 Efforts and suggestions for how to improve quality have been wide ranging. They include a focus on improving the systems within which health professionals work, improving the processes of patient care, educating health professionals about techniques for quality improvement, and development of various incentives such as pay-for-performance.4-7 While many health care organizations collect information on clinical performance variations, little is known about the actual combination of policies and strategies applied in practical situations to address differences. The overarching aim of this research is to gather information on the policy and managerial strategies to reduce performance variations employed by identified ‘high-performing’ health care providers. The focus on high-performance is for the fact that high performers may be more likely to have sought to tackle, and to have had experience with, the issues this project seeks to probe (of course, such organizations may also attract higher-performing clinical staff, but variations in practice are still likely). Organizations to be studied will be sought via analysis of existing frameworks and data sets. In this way, an objective set of measures may be used to identify high-performers. Potential cases for study may include winners of the Malcolm Baldrige National Quality Award scheme and the American Hospital Association McKesson Quality Prize. Cases may also be selected through analysis of the Medicare Hospital Compare data set. A case study approach will form the principal method of inquiry.8 The proposed research has high relevance in both the U.S. and New Zealand context. The U.S. federal government’s 2005 Patient Safety and Quality Improvement Act indicates that quality improvement is on the government’s agenda. The findings ought to be of interest to organizations with a specific mandate to advance understanding of ways to improve quality and reduce performance variations. Examples include the Agency for Healthcare Research and Quality, the Hospital Quality Alliance, Institute for Healthcare Improvement, Joint Commission and, of course, The Commonwealth Fund. Quality in New Zealand, especially variation in performance, is a particularly important issue. New Zealand has a largely government-funded health system, with public institutions dominating hospital care. A notable feature of the system is highly-devolved local service planning and funding structures, with 21 District Health Boards (DHBs).9 There is no national quality improvement framework or strategy, and nationally collected data on variations is minimal. In turn, each of the 21 DHBs has individual responsibility for quality, meaning that there is considerable variation in the approaches in place. Furthermore, few of the individual DHBs have strategies to deal with clinical performance variations. The proposed research is, therefore, of considerable relevance to New Zealand in terms of developing both national strategies for reducing performance variations, as well as individual within-DHB approaches. Through the case studies, the research aims to explore a range of questions. These include:

EXEMPLAR PROPOSED HARKNESS PROJECT I

1. Is a mix of measures used, such as financial incentives, audit and feedback, and individual profiling? Which ones, in which combination, and in what context? 2. Do some organizations use only non-financial measures? If so, what shape do these take? 3. Have some organizations experimented over time with different models aimed at reducing variations and what has been the experience with these? Why have they shifted from one model to another? 4. How and why have organizations developed their strategies? Who has been involved in the development process? What were the reasons for strategy development? 5. What lessons might be gleaned from the experiences of case study subjects? The intended outcome of the study is to advance understanding of the techniques used to reduce clinical performance variations, to provide lessons for performance and service quality improvement, and to lay the groundwork for a broader research program. B. Research Design As noted above, a list of issues related to reducing performance variation need to be better understood. In keeping with this, a case study method will be used.8 The above list of research questions and the proposed research design will most likely need to be further refined as discussions with mentors and others progress. It is also possible that the case study approach could evolve once the research has commenced. For example, it may be that the completion of one or two case studies could highlight a series of central issues that might be explored through a survey approach; a clearer picture could also be gained of the key individuals within individual organizations who may be targeted for surveying. The research will progress in two phases: Phase one: Preparatory work This phase will establish the extent of existing knowledge about strategies to reduce clinical performance variations. This will involve: (1) A comprehensive literature review that will inform the subsequent research. This will include searching article databases as well as accessing material in the public domain (such as reports by health care organizations), using common Internet search engines. It may, if accessible, also include documentation submitted by Baldrige and McKesson award winners. Resulting material will be read, categorized, summarized and filed for later reference. (2) Conducting discussions with leaders in the field including academics, members of provider organizations, and quality improvement advocates. (3) Based on 1 and 2, refining the issues to be probed through the case studies that compose Phase two. Phase two: Field work case studies This phase will aim to produce some answers to the refined research questions. It will consist of in-depth case studies, conducted as follows: (1) In keeping with the focus on high-performing organizations, a sample will be drawn from analysis of Baldridge and McKesson award winners and from analysis of Medicare Hospital Compare data. A maximum-variation sampling approach will seek to identify different types of organizations to be selected for case study (e.g., that employ their staff in differing ways such as direct salary or fee-for-service; vary in size and community served; are public, or for-profit, or non-profit). An initial list of

EXEMPLAR PROPOSED HARKNESS PROJECT I

around ten possible organizations will be compiled in the hope that, on being approached, around four will agree to participate. (2) Case study methods will include review of available written material on relevant policies and strategies, site visits, and interviews with identified key informants. Interviewees will predominantly serve in managerial positions. Depending on organizational structure and size, between 10-20 interviews may be conducted for each case study. The interviews will be taped and notes taken, and a summary produced immediately after. (3) On completion of each case study, written material will be categorized for later reference. Interview data will be transcribed and analyzed for key themes. Phase three: Survey of Chief Quality Officers This phase will explore the views and experiences of chief quality officers in all acute care hospitals in four states on reducing unwarranted variation. Questions to be asked include: (1) Whether unwarranted variations are a major concern; (2) What strategies their hospitals employ to reduce unwarranted variations, such as pay for performance or un-blinded performance report cards; (3) What they have found to be the barriers and facilitators to reduce unwarranted variation. C. Expected Contributions of the Proposed Research The proposed research has the potential to make a significant contribution. For the U.S., the research ought to provide important information about the strategies that selected organizations use to reduce clinical performance variations. The research should lay the groundwork for a broader research program around strategies for performance variation reduction. General lessons for quality improvement may also result. The potential for New Zealand is considerable, especially if it can be demonstrated that effective strategies for reducing performance variations exist that could be applied in the New Zealand context. D. Dissemination Strategy Strategies include submitting articles to journals that publish case study research, such as the Milbank Quarterly, Health Affairs, Quality and Safety in Health Care, and the Journal of Health Policy, Politics and Law. Seminars and conference presentations will be made in the U.S. during the Harkness Fellowship as research results emerge and opportunities arise. In New Zealand, offers will be made to present findings to Ministry of Health and the DirectorGeneral. There should also be presentations at conferences such as the Health Services Research Association of Australia and New Zealand, and the respective Australian and NZ Public Health Associations. E. Workplan September

October

November December January February

Arrive; meet mentors; get settled; commence literature review; start setting up exploratory discussions with key informants Continue literature review; conduct exploratory discussions; compose case study sample; approach case study organizations Complete literature review; conduct first case study Second case study Third case study Fourth case study

EXEMPLAR PROPOSED HARKNESS PROJECT I

March April May June July

Case study analysis Case study analysis Start drafting articles; give presentations Article drafting; presentations Article drafting

F. Proposed Placement in the United States G. Proposed Home Country Mentor H. Research References/Footnotes

1. Grol R, Berwick D, Wensing M. On the Trail of Quality and Safety in Health Care. British Medical Journal 2008;336:74-76. 2. Wennberg JE. Understanding Geographical Variations in Health Care Delivery. New England Journal of Medicine 1999;340:52-53. 3. Jha AK, Orav EJ, Li Z, Epstein AM. The Inverse Relationship Between Mortality Rates and Performance in the Hospital Quality Alliance Measures. Health Affairs 2007;26(4):11041110. 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-First Century. Washington: National Academy Press, 2001. 5. Epstein AM. Paying for Performance in the United States and Abroad. New England Journal of Medicine 2006;355:406-408. 6. Jain M, Miller L, Belt D, King D, Berwick D. Decline in ICU Adverse Events, Nosocomial Infections and Cost Through a Quality Improvement Initiative Focusing on Teamwork and Culture Change. Quality and Safety in Health Care 2006;15:235-239. 7. Jamtvedt G, Young JM, Kristoffersen DT, O'Brien MA, Oxman AD. Does Telling People What They Have Been Doing Change What They Do? A Systematic Review of the Effects of Audit and Feedback. Quality and Safety in Health Care 2006;15:433-436. 8. Bowling A. Research Methods in Health: Investigating Health and Health Services. Buckingham: Open University Press, 1997. 9. Gauld R. One country, four systems: comparing changing health policies in New Zealand. International Political Science Review 2003;24(2):199-218.